Fenestrated/Branched Endovascular Aortic Repair Using Unilateral Femoral Access in Patients with Iliac Occlusive Disease

OBJECTIVES: Fenestrated/branched endovascular aortic repair (F/BEVAR) in patients with occluded iliac arteries is challenging due to limited access for branch vessel catheterization and increased risk for leg and spinal ischemic complications. The aim of this study was to analyze technical strategies and outcomes of F/BEVAR in patients with unilateral iliofemoral occlusive disease (UIOD).

METHODS: We performed a retrospective review of all consecutive patients treated by F/BEVAR in two institutions (2003-2021). Patients with UIOD were included in the analysis. All patients had one patent iliac artery which was used for advancement of the fenestrated-branch component. Preloaded catheter/guidewire systems or steerable sheaths were used as adjuncts to facilitate catheterization. Primary endpoints were technical success, mortality, major adverse events (MAEs: stroke, spinal cord injury, dialysis/GFR decline >50%, bowel ischemia, myocardial infarction or respiratory failure), primary iliac patency and freedom from reinterventions.

RESULTS: There were 959 patients treated by F/BEVAR. Of these, 15 patients (1.56%, mean age 74, 80% male) had occluded iliac arteries and one patent iliofemoral access and were treated for a thoracoabdominal aortic aneurysm (8) or juxtarenal abdominal aortic aneurysm (7). Brachial access was used in 14/15 patients and preloaded systems in 7/15 patients (47%). The remaining 53% had staggered deployment of stent grafts. There were 7 physician-modified endovascular grafts, 7 custom-made devices and 1 off-the-shelf device used. Thirteen (87%) patients had distal seal using AUI stent-grafts and two (13%) had distal seal in the infrarenal aorta. Concomitant femoral crossover bypass (FCB) was performed in 2 patients and 6 patients had a prior FCB. Technical success was 100%. There were no intra-operative complications or early lower extremity ischemic complications and all FCB were preserved. There was one 30-day mortality (7%) due to retrograde type A dissection. MAEs occurred in 20% of patients. Median follow-up was 12 months (0-85). Two patients (13%) required three reinterventions. One patient required proximal stent-graft extension for an acute type B dissection (3 months) and another required iliac extension for type Ib endoleak of an AUI (21 months) and thrombolysis of that extension (50 months). At last follow-up all patients had primary graft patency except one with secondary graft patency without new claudication. One patient had a single renal artery stent occlusion at follow-up with no re-intervention. Overall survival was 60%, without aortic-related deaths.

CONCLUSIONS: Although challenging, F/BEVAR with unilateral femoral/brachial approach is feasible in patients with occluded iliac limbs, with an important rate of ischemic complications but satisfactory outcomes.